The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer

BACKGROUND: Multiple factors may influence whether patients undergo immediate breast reconstruction along with mastectomy for breast cancer. The authors investigated whether ethnicity was an independent predictor of immediate breast reconstruction. METHODS: The authors identified 1004 patients who underwent mastectomy for breast cancer during the period 2001-2002. The rates of immediate reconstruction among different ethnicities were evaluated using the chi-square test. Logistic regression was used to adjust for covariates, including age and disease stage. Medical records were analyzed to identify factors that influenced each patient's decision for or against immediate breast reconstruction. RESULTS: Three hundred seventy-six women (37.5%) underwent immediate breast reconstruction: This included 20.2% of African-American women, compared with 40.0% of white women, 42.0% of Hispanic women, 42.2% of Asian women, and 10.0% of Middle Eastern women (P < 0.001). The unadjusted odds ratio (OR) for immediate reconstruction for African-Americans versus whites was 0.38 (95% confidence interval [95% CI], 0.23-0.63; P < 0.001). After multivariate analysis, this disparity persisted, with an adjusted OR of 0.34 (95% CI, 0.18-0.62; P = 0.001). Asian women had lower rates of immediate reconstruction compared with white women (adjusted OR, 0.50; 95% CI, 0.24-1.04; P = 0.06). Hispanic women did not have immediate reconstruction rates that differed significantly from white women. Middle Eastern women had lower rates of immediate reconstruction compared with white women (adjusted OR, 0.08; 95% CI, 0.02-0.38; P = 0.002), but they had a corresponding increase in the rate of delayed reconstruction. In a stepwise analysis of the decision pathway to immediate reconstruction, it was found that African-American women were less likely to be offered referrals for reconstruction, were less likely to accept offered referrals, were less likely to be offered reconstruction, and were less likely to elect reconstruction if it was offered. CONCLUSIONS: African-American women underwent immediate breast reconstruction at significantly lower rates compared with white women, Hispanic women, and Asian women. After adjusting for covariates, including age and disease stage, African-American women and Asian women had lower rates of reconstruction compared with white women. The factors that contribute to these differences warrant further study.     

Trastuzumab, paclitaxel, cisplatin, and radiation for adenocarcinoma of the esophagus: a phase I study

Purpose: To conduct a phase I study incorporating trastuzumab with paclitaxel, cisplatin, and radiation for adenocarcinoma of the esophagus. Methods and Materials: Patients with adenocarcinoma of the esophagus without distant organ metastases were eligible. All patients received cisplatin 25 mg/m² and paclitaxel 50 mg/m² weekly for 6 weeks with radiation 50.4 Gy. HER-2/neu-positive patients (2 + /3 + by immunohistochemistry) received weekly trastuzumab at dose levels of 1, 1.5, or 2 mg/kg weekly for 5 weeks after an initial bolus of 2, 3, or 4 mg/kg, respectively. HER-2/neu-negative patients received the same chemoradiation without trastuzumab as a control for toxicity. Dose-limiting toxicities were defined as grade 3 esophageal, cardiac, or pulmonary toxicity. Results: Twelve of 36 screened patients (33%) overexpressed HER-2/neu by immunohistochemistry (seven 3 + and five 2 + ). Eight of 12 patients with HER-2/neu overexpression by IHC had an increase in the number of HER-2/neu genes, six from amplification of the HER-2/neu gene and two were hypderdiploid for chromosome 17. Thirty patients were enrolled (12 HER-2/neu-positive and 18 HER-2/neu-negative controls). No increase in toxicity was seen with the addition of trastuzumab. One of 12 patients in the trastuzumab arm and 8 of 17 in the control arm had grade 3 esophagitis (p ≤ .026). Mean left ventricular ejection fraction for the trastuzumab group was 57% before treatment and 56% after treatment. Conclusion: HER-2/neu is overexpressed in approximately one-third of esophageal adenocarcinomas. Trastuzumab can be added at full dose to cisplatin, paclitaxel, and radiation. Future studies of trastuzumab in esophageal adenocarcinoma are indicated.     

Diagnosis of deep septic thrombophlebitis in cancer patients by fluorine-18 fluorodeoxyglucose positron emission tomography scanning: a preliminary report.

PURPOSE: To determine the role of the fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) scan in the diagnosis and management of deep septic thrombophlebitis (STP). PATIENTS AND METHODS: We conducted a prospective observational evaluation of FDG-PET in patients with cancer and suspected STP. Retrospective evaluation of patients with cancer and deep venous thrombosis (DVT) who underwent FDG-PET and extremity duplex scan (DS) was also performed. RESULTS: Strong venous uptake was observed in FDG-PET of nine STP episodes versus 0 of 27 DVT episodes (P <.001). FDG-PET identified central vein STP in five patients, whereas DS and venography were negative in five and two of these patients, respectively. FDG-PET diagnosis of STP resulted in therapeutic changes in all patients. In four patients, follow-up FDG-PET confirmed resolution. CONCLUSION: In cancer patients, FDG-PET identifies STP even in areas not optimally visualized by DS or venography, distinguishes STP from DVT, and leads to significant therapeutic changes.     

The effect of a new toothpaste containing potassium nitrate and triclosan on gingival health, plaque formation and dentine hypersensitivity

OBJECTIVES: The purpose of this study was to investigate the effect of a new toothpaste containing an antiplaque and antiinflammatory agent (0.3% triclosan), a desensitizing agent (5% potassium nitrate) and an anticaries agent (0.76% sodium monofluorophosphate (SMFP)) on gingival health, plaque formation and dentine hypersensitivity in a 12-week home study. The efficacy of the test toothpaste was compared with that of a control toothpaste containing 5% potassium nitrate and 0.76% SMFP and a benchmark product containing only 0.76% SMFP. MATERIAL AND METHODS: One hundred and two healthy volunteers, who had a minimum of 20 natural permanent teeth with no probing depth >4 mm and at least one sensitive tooth, participated in this study. Following enrollment, the subjects received a dental prophylaxis and instruction in brushing technique. After a 4-week pre-experimental phase, baseline gingival bleeding index (GBI), plaque index (PI) and visual analogue scales (VASs) indicating dentine hypersensitivity levels responding to tactile and air stimuli were assessed. The subjects were then randomly given one of the three toothpastes; test, control, or benchmark toothpaste, and a soft-filamented toothbrush for home use. The GBI, PI and VASs were re-examined at weeks 4 and 12. RESULTS: Overall, the GBI scores were significantly reduced compared with baseline in all groups (p<0.01). However, there was no significant difference in GBI score among the three comparison groups. The PI score decreased in the test group and benchmark group from baseline to the end of study, whereas there was no significant change in the control group. Post hoc comparison indicated that the PI score was not statistically different between the three groups. There was a significant difference between the three treatment groups for sensitivity. For both the tactile and air stimuli, the reductions in VAS sensitivity scores for the test group and the control group were significantly greater compared with the benchmark group. Although the sensitivity score for air stimulus decreased more rapidly from baseline to week 4 in the test group, there was no overall difference between the test group and the control group. CONCLUSIONS: This study demonstrated that the new toothpaste was effective in reducing dentine hypersensitivity. More studies are needed to further determine the potential interaction between triclosan and potassium nitrate in dentifrices.     

Tumoral calcinosis

Tumoral calcinosis is an unusual clinical disorder in which large masses of calcium are deposited in the periarticular tissues of the body. The characteristic clinical, radiological and histopathological features of this disorder occurring in three middle aged female patients are reported.     

Melioidotic septic arthritis: a case report and literature review.

Burkholderia pseudomallei, the causative agent of melioidosis, is endemic in southeast Asia and northern Australia. In recent years, the incidence of melioidosis has increased worldwide. Septic arthritis is a rare but well-recognized manifestation of melioidosis. Patients with underlying medical conditions, such as diabetes mellitus, renal impairment, cirrhosis, and malignancy are at greater risk. The presentations of melioidotic septic arthritis often mimic other disease processes and patients may not always be clinically septic. We present a case of septic arthritis due to B. pseudomallei in a 66-year-old male with diabetes mellitus presenting with a history of fever and ankle swelling. Follow-up ankle X-ray showed soft tissue swelling. Synovial fluid and blood samples grew B. pseudomallei. The patient improved gradually after parenteral administration of ceftazidime (2 g 8-hourly) and cotrimoxazole (1440 mg 8-hourly). He was discharged on oral cotrimoxazole (1440 mg 12-hourly), doxycycline (100 mg 12-hourly), and chloramphenicol (500 mg 6-hourly) for 6 months. This case highlights the possible occurrence of melioidotic septic arthritis, and the importance of prompt initiation of appropriate antimicrobials to achieve good outcomes.     

Upper dorsal endoscopic thoracic sympathectomy: a comparison of one- and two-port ablation techniques.

OBJECTIVE: Facial blushing and hyperhidrosis, particularly in the facial, axillary or palmar distribution, are socially, professionally, and psychologically debilitating conditions. Endoscopic thoracic sympathectomy can be carried out through multiple ports or by using a single port and a modified thoracoscope with integrated electrocautery. We reviewed our own experience to compare outcomes between these methods. METHODS: One hundred and nine consecutive endoscopic thoracic sympathectomies performed on 96 patients (M:F, 30:66) were examined with respect to operative method, symptom control, and patient satisfaction. Complete follow-up was available on 144 treated sides in 77 patients (80.2%), 38 treated with two ports, 39 performed by a one-port procedure. Mean age was 32.6 years (range 18-63) with a median follow-up of 25 months (range 5-85). Pooled data showed that the mean duration hospital stay was 1.6 nights with no deaths, conversions, or neurological injuries. RESULTS: The one-port group showed superior outcomes in terms of hospital stay, rate of postoperative pneumothorax, and the need for chest drain insertion; however, there was no correlation between number of ports and patient satisfaction. The mean overall satisfaction rating out of 5 was 3.3 with 76.6% of patients rating the outcome as 3 or more. 90.9% had an initial improvement in symptoms, although 21 patients (27.3%) described a late return of symptoms. CONCLUSION: Endoscopic thoracic sympathectomy can be safely and effectively carried out using a single port with similar results to the traditional two-port procedure. The one-port procedure may allow for a shorter duration of stay and lower complication rate.     

Access for endovascular aneurysm repair.

Despite advancement in stent-graft technology, access-related problems continue to occur during endovascular repair of aortic aneurysms. Various techniques have been adopted to overcome difficult access situations, however. To survey these developments in arterial access, we performed a systematic literature review from 1994 through 2005 to identify relevant articles pertaining to endovascular access techniques and complications. Excessive iliac tortuosity, circumferential vessel wall calcification, significant occlusive disease, and small caliber vessels account for the majority of access problems, most of which are readily apparent with adequate baseline imaging. Even with careful preoperative assessment, however, some access problems may not be foreseen; nonetheless, the majority can be overcome using today's array of ancillary procedures, such as an iliac conduit, a brachiofemoral wire, or arterial reconstruction. Alternatively, other approach routes, such as the common carotid artery or direct aortic access, may be used to facilitate endovascular aneurysm repair.     

Disseminated invasive aspergillosis in an apparently immunocompetent host.

Aspergillosis is a spectrum of diseases caused by members of the genus Aspergillus that continues to pose a significant threat to immunocompromised, organ transplant, neutropenic and cancer patients. In view of increasing risk factors leading to invasive aspergillosis, it is imperative for clinicians to be familiar with the clinical presentation, diagnostic methods and management of the disease. We describe a 34-year-old immunocompetent male patient receiving chemotherapy for Aspergillus fumigatus infection that had disseminated to lung, liver and spleen. A computed tomogram of thorax and abdomen showed thick-walled cavities of different sizes with air fluid levels, consolidation in both lungs and involvement of liver and spleen. His broncheoalveolar lavage and sputum specimens yielded A. fumigatus. Successful treatment of this infection was achieved with amphotericin B and itraconazole.